Vessel Harvesting

ABSTRACT

Apparatus and method for harvesting selected vessels in the body of a patient include manual manipulation of a rigid dissecting endoscope and the reconfiguration thereof to facilitate tissue dissection and tissue dilation in the formation of an anatomical space about the vessel within which side-branch vessels may be manipulated in preparation for severance and removal of the vessel from the anatomical space.

RELATED APPLICATIONS

This application is a divisional of pending U.S. patent application Ser.No. 10/054,477, filed on Jan. 18, 2002, which is a continuation-in-partof pending U.S. patent application Ser. No. 09/413,012 filed on Oct. 5,1999, which is a continuation of U.S. patent application Ser. No.09/133,136 filed on Aug. 12, 1998, now abandoned, and the subject matterof this application relates to the subject matters described in U.S.Pat. No. 6,176,825 issued on Jan. 23, 2001 and in U.S. Pat. No.5,980,549 issued on Nov. 9, 1999, and in U.S. Pat. No. 6,951,568 issuedon Oct. 4, 2005, which subject matters are incorporated herein by thesereferences.

FIELD OF THE INVENTION

This invention relates to surgical instruments and procedures forsubcutaneously harvesting blood vessels particularly for use in coronarybypass surgery.

BACKGROUND OF THE INVENTION

Contemporary coronary bypass surgery commonly entails grafting a segmentof a patient's own blood vessel around a stenosis or other anomaly in acoronary artery to improve circulation in regions of the cardiac muscleadversely affected by diminished blood flow past such stenosis oranomaly. The bypass or shunting vessel is commonly prepared from thepatient's saphenous vein or radial artery, and minimally invasivetechniques are now routinely employed to harvest a segment of such veinusing subcutaneous surgical instruments and procedures that dissect thesaphenous vein from connective tissue to promote convenient harvestingof the vessel with minimal cutaneous incision.

Specifically, common surgical practices for harvesting the saphenousvein include making a small incision over the vein near the knee toexpose the vein and facilitate introduction of an elongated tissuedissector to dissect connective tissue from the vein along its course ineither or both directions from the incision near the knee. The saphenousvein may thus be separated from surrounding connecting tissue, and theanatomical space or cavity thus formed along the course of the vesselmay be maintained open under insufflation of the cavity to facilitateoperation on the vein. To implement such maintenance of a working spaceabout the vessel being harvested, an access port with a sliding gas sealmay be installed in the initial incision and endoscopic instruments maybe passed through the seal and manipulated to harvest the vessel fromwithin the cavity which is expanded by gas supplied thereto underpressure. Lateral or side branches of the vessel may be cauterized orotherwise ligated and transected to free the saphenous vein fromanatomical attachments and then severed near extreme ends of the cavityfor removal from the body, for example, through the initial incision.

In such vessel harvesting procedure, it is highly desirable to havevisualization of the vessel as tissue is bluntly dissected away from thevessel and around side branches within the cavity, and it is highlydesirable to have endoscopic instruments selectively available at thedistal end of an elongated device that is manipulable within theinsufflated anatomical space through a gas-seal to occlude and severside branches of the saphenous vein in preparation for harvesting of thevessel from the patient's body. Similarly, it is highly desirable toestablish minimally invasive techniques for harvesting a radial artery.

However, harvesting an arterial conduit is more difficult and hazardousthan harvesting a venous conduit. Inadvertent transection of an arterialside branch during tissue dissection leads to hemorrhage from theartery, which is under high pressure. The dissection tunnel immediatelyfills with blood, and prevents visualization of the vessel for furtherexposure of the artery. If a side branch is stretched and partiallyavulsed or torn, the high pressure in the artery causes blood to dissectalong the medial and adventitial layers of the artery, expanding thewall of the artery like a balloon, and ruining the vessel for use as agraft.

SUMMARY OF THE INVENTION

In accordance with an embodiment of the present invention, an elongatedtissue-dissecting endoscope includes a blunt tissue-dissecting tip atthe distal end of a rigid shaft for visualizing tissue at the surgicalsite at which connecting tissue is bluntly dissected away from thevessel. This procedure may be effected through an initial incisionthrough which the vessel is exposed, and in which a sliding gas seal isinstalled to facilitate insufflation of the anatomical space that isformed about the vessel as connecting tissue is dissected away from thevessel along its course by the tip at the distal end of thetissue-dissecting endoscope.

After sufficient length of the vessel is dissected away from connectingtissue, the dissecting endoscope may be withdrawn from the cavity thusformed, and the tissue-dissecting tip removed therefrom (if installed asa removable tip) to accommodate reconfiguring the dissecting endoscopewith an overlying tool cannula. Alternatively, a different endoscopewith no dissecting tip can be used in the tool cannula. The tool cannulacarries bipolar scissors, bisector, or other transecting or ligatingdevice (e.g., a clip applier, an ultrasonic or radio frequencycauterizer), and a vein retractor or other surgical effector that areeach selectively deployable from the open distal end of the tool cannulafor selectively manipulating tissue and the vessel such as the saphenousvein as side branches are ligated (e.g., cauterized) and transectedalong the course of the vessel. The proximal end of the tool cannulaincludes controls for selectively deploying and manipulating the bipolarscissors or vein retractor or other type of surgical effectors such asoperating the bipolar scissors in electrocauterizing and severing modes.Various configurations of proximal-end control devices mounted on thetool cannula facilitate manual manipulation at the distal end of thesurgical effector devices during the procedures required to isolate thevessel from side-branch vessels within the bluntly-dissected andinsufflated cavity formed in the surrounding tissue. The dissectingendoscope with an overlying or adjacent tool cannula in one of aplurality of configurations of surgical effectors may be insertedthrough and manipulated within the sliding-gas seal of an access portthat is disposed within the initial incision to facilitate convenientside-branch cauterization and transection within the cavity inpreparation for harvesting of the vessel from the patient's body.

Harvesting an artery such as the radial artery in accordance with anembodiment of the present invention involves temporary use of atourniquet proximal to the artery to be harvested in order to cut offflow through the artery during endoscopic harvesting. The extremitycontaining the artery to be harvested may be externally wrapped prior toactivation of the tourniquet. The external wrap exsanguinates theextremity by forcing blood out of the arteries and veins, and thetourniquet maintains the bloodless state in the vessels. In oneembodiment of the invention a less significant structure such as a veinadjacent to the artery is tracked using the transparent blunt tip of thedissecting endoscope to form a cavity around the artery without exertingshear force directly on the wall of the artery. Any arterial branchesthat are avulsed during harvesting are avulsed away from the main trunkof the artery. Many arteries are paired with a vein, and dissection of acavity around a vein using the dissecting endoscope will also form acavity around the artery, with much less risk of injury to the artery.

In the case of the radial artery, small diameter veins termed “venaecomitantes,” lie on each side of the artery, and run along the length ofthe artery, as shown in FIG. 1A.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1A is a pictorial illustration of the radial artery and adjacentveins within a forearm;

FIG. 1B is a perspective view of a dissecting endoscope according to oneembodiment of the present invention;

FIG. 2A is a perspective view of a tissue dilator having facetedsurfaces according to the present invention;

FIGS. 2B and 2C are, respectively, front and end views of anotherembodiment of a tissue dilator in accordance with the present invention;

FIGS. 3A-3C are partial side views of tissue-dissecting tips anddilators attached to the distal end of a dissecting endoscope accordingto the present invention;

FIGS. 3D-3F are perspective views of surgical effector devicesselectably attached to the distal end of a dissecting endoscopeaccording to the present invention;

FIG. 4 is a pictorial illustration of an optically-enhancedtissue-dissecting tip attached to a dissecting endoscope according tothe present invention;

FIG. 5 is a perspective view of another attachment structure accordingto the present invention;

FIGS. 6A and 6B are partial exploded and sectional views of anotherattachment structure according to the present invention;

FIG. 6C is a partial pictorial illustration of another locking structureaccording to the present invention;

FIGS. 7A and 7B are pictorial illustrations of in-line and offsethandles, respectively, attached to the proximal end of a dissectingendoscope in accordance with the present invention;

FIG. 8 is an exploded view of a vessel harvester in accordance with oneembodiment of the present invention;

FIG. 9 is a perspective view of the distal end of one embodiment of avessel harvester according to the present invention;

FIGS. 10, 11 and 12 are perspective views of alternative embodiment ofvessel harvesters according to the present invention;

FIGS. 13 and 14 are partial perspective views of rotational tissuecutters according to the present invention;

FIGS. 15A and 15B are partial perspective views of alternativeembodiments of rotational tissue cutters according to the presentinvention;

FIG. 16 is a perspective view of another embodiment of a tissue cutterin accordance with the present invention;

FIG. 17 is a pictorial illustration of another embodiment of a tissuecutter in accordance with the present invention;

FIG. 18 is a pictorial illustration of another embodiment of a tissuecutter in accordance with the present invention;

FIG. 19 is a pictorial illustration of a tissue cutter combined with atissue-dissecting tip in accordance with the present invention;

FIGS. 20A and 20B are partial pictorial illustrations of anotherembodiment of a tissue cutter combined with a tissue-dissecting tip inaccordance with the present invention;

FIGS. 21A and 21B are pictorial illustrations of a tissue cauterizingand cutting device according to one embodiment of the present invention;

FIG. 22 is a partial perspective view of a surgical effector device forpositioning a suture in accordance with the present invention;

FIGS. 23A, 23B and 23C are partial side views of a tissue cauterizingand cutting device in accordance with the present invention;

FIGS. 24A-24I are partial top, side, end and perspective views of atissue cutting and cauterizing devices according to other embodiments ofthe present invention;

FIGS. 25A-25D are partial perspective views of surgical effector devicesin accordance with additional embodiments of the present invention;

FIGS. 26A and 26B are partial perspective views of surgical effectordevices in accordance with additional embodiments of the presentinvention;

FIGS. 27A and 27B are partial perspective views of a vessel retractor inaccordance with one embodiment of the present invention;

FIG. 28 is a partial perspective view of a vessel retractor according toanother embodiment of the present invention;

FIG. 29 is a partial perspective view of a vessel retractor according toanother embodiment of the present invention;

FIGS. 30A and 30B are perspective views of modified vessel retractors inaccordance with other embodiments of the present invention;

FIG. 31 is a partial perspective view of a vessel retractor according toanother embodiment of the present invention;

FIG. 32 is a perspective view of the vessel retractor of FIG. 8;

FIG. 33 is a partial perspective view of a vessel retractor inaccordance with another embodiment of the present invention;

FIGS. 34A-34I are perspective views of components forming the vesselharvester of the embodiment illustrated in FIG. 8;

FIG. 35 is a frontal view of another embodiment of control members for avessel harvester in accordance with the present invention;

FIG. 36 is a frontal view of another embodiment of control members for avessel harvester in accordance with the present invention;

FIG. 37 is an exploded perspective view of components assembled in a kitfor harvesting a vessel;

FIGS. 38A and 38B comprise a flow chart illustrating a vessel harvestingprocedure in accordance with the present invention; and

FIGS. 39A and 39B comprise a flow chart illustrating a procedure forharvesting the radial artery in accordance with the present invention.

DETAILED DESCRIPTION OF THE INVENTION

Vessel Harvesting.

In accordance with the present invention, a vessel such as the saphenousvein in the leg or the radial artery in the forearm is selectivelyharvested for use in another part of a patient's body, for example, as agraft vessel in coronary arterial bypass surgery. The vessel harvestingproceeds with conventional preparation of the patient's leg or forearmfor an initial incision at a selected location along the course of thevessel, such as at the knee, groin or ankle for the saphenous vein, orat the wrist for the radial artery, followed by manual tissue dissectionto expose the vessel beyond the initial incision. An anatomical space isformed in tissue surrounding the vessel to an extent sufficient tointroduce an access port such as a hollow trocar for gas-tight sealedengagement within the incision.

In accordance with an embodiment of the invention, a rigid endoscope asmore fully described later herein is configured at the distal end withone or other surgical effector devices and is introduced through asliding gas seal within the access port in order to dissect tissue awayfrom the saphenous vein along its course. The anatomical space thusformed along the vessel is simultaneously insufflated with gas underpressure to hold the space open and facilitate convenient dissection oftissue away from the vessel and its associated side-branch vessels, aswell as to provide a tamponade effect on the exposed vessels and tissue.

The distal end of the tissue-dissecting endoscope is configured with arigid tapered tip of transparent material to facilitate visualizationthrough the tip of tissue being dissected by the tip along the course ofthe vessel. Adherent tissue may be so dissected away from anteriorportions of the vessel, followed by dissection of tissue in similarmanner away from posterior portions of the vessel in order to isolatethe vessel and adjacent portions of side-branch vessels from adherenttissue. Alternatively, tissue may be dissected from posterior portionsof some vessels followed by dissection of tissue from anterior portions.

The dissecting endoscope may then be withdrawn from the anatomical spacethus formed in dissected tissue along the course of the saphenous veinto be reconfigured in accordance with the present invention withadditional instrumentation as later described herein for performingadditional surgical procedures associated with harvesting the saphenousvein. Specifically, an elongated sheath or tool cannula carryingsurgical effector devices may be disposed about or adjacent thedissection endoscope to selectively position such surgical effectordevices as vein retractor, tissue shears, bipolar electrocauterizer, andthe like, at selected locations within the anatomical space along thecourse of the saphenous vein. The dissecting endoscope as reconfiguredwith associated sheath or tool cannula is introduced through the accessport into the anatomical space previously formed along the course of thesaphenous vein. Side-branch vessels may be ligated and transected undervisualization through the dissecting endoscope in response tomanipulation of selected surgical effector devices that are disposed atthe distal end of the cannula in response to manual manipulation ofcontrols that are positioned near the proximal end of the cannula. Asegment of the saphenous vein thus isolated from adherent tissue andside-branch vessels may then be removed from within the insufflatedanatomical space for subsequent preparations and use in another part ofthe patient's body.

The radial artery, as illustrated in FIG. 1A, may be harvested inaccordance with an embodiment of the present invention as follows.

A mark may be made on the skin at the wrist overlying the pulse of theradial artery. A sterile marking pen may be used for this purpose. Thelower arm is wrapped with an elastic band (Esmarch bandage) to forceblood out of the limb, followed by application of an inflatabletourniquet to the upper arm. The Esmarch bandage is removed, and a skinincision is made in the wrist at the spot marked at the site of theradial artery. Blunt dissection is performed using Metzenbaum scissorsto expose the radial artery 4 and the adjacent veins, the venaecomitantes 5. The tapered tip 11 of the dissecting endoscope 9, as shownin FIG. 1B, is placed on the anterior aspect of one of the veins 5 lyingadjacent to the radial artery with a hollow trocar disposed around theendoscope for forming a sliding gas seal therewith. The tip 11 isadvanced sufficiently far to allow the balloon of the trocar to besealed within the incision to initiate gas insufflation in the arm. Thevein 5 is tracked to the antecubital space at the elbow, and theendoscope 9 is then pulled back to the trocar and advanced on theposterior aspects of the vein 5. Next, the tip 11 of the endoscope 9 isplaced on the anterior surface of the vein 5 on the other side of theradial artery 4. Anterior dissection and posterior dissection on thesecond vein 5 is performed. The tip 11 of the endoscope 9 is used toexpose both venous and arterial branches along the length of the tunnel,until a pedicle consisting of the radial artery 4 and its adjacentpaired veins 5 has been isolated. The endoscope 9 is removed from thetunnel, and a tool cannula, as described in detail later herein, isintroduced to cauterize and transect the venous tributaries and arterialbranches emanating from the isolated radial artery pedicle.Cauterization and transection of the side branches and tributaries areperformed as they appear, with the side branches and tributaries closestto the trocar taken down first. The procedure continues withcauterization and transection, working from the wrist to the elbow,until all connections have been severed. A small counterincision isperformed at the elbow, and the pedicle consisting of radial artery andpaired veins is ligated with a suture and transected. The pedicle islikewise ligated and transected at the wrist, to complete the harvest ofthe radial artery pedicle. The tourniquet is deflated, and any bleedingpoints are identified and cauterized, and the incisions are then closedto complete the procedure.

The procedure described above may be used to harvest other delicatestructures in the body. For example, if endoscopic harvest of a nerve isdesired, and a vein runs parallel to the nerve, the vein may be trackedwith the dissecting endoscope 9 to expose the nerve with less potentialfor nerve injury. For example, the sural nerve lies close to the lessersaphenous vein in the posterior aspect of the lower leg, and endoscopicharvest of the sural nerve may be accomplished by tracking along thelesser saphenous vein to form the working cavity around the nerve.Harvest of the internal mammary artery may also be performed by trackingalong the adjacent internal mammary vein, followed by cauterization andtransection of venous and arterial branches. An internal mammary arterypedicle is harvested, similar to the radial artery pedicle, but with oneless vein attached.

Dissecting Endoscope.

Referring now to the perspective view of FIG. 1B, there is shown atissue-dissecting endoscope 9 in accordance with one embodiment of thepresent invention that is fitted with a blunt tissue-dissecting tip 11which includes transparent rigid, substantially conically-tapered wallsthat are aligned within the field of view through the dissectingendoscope 9. The dissecting endoscope 9 is formed within a rigid tube 10that is substantially filled with optical imaging and illuminationcomponents and that is sufficiently rigid to protect the internaloptical component from damage while withstanding the forces, torques,and bending moments encountered during tissue dissection along thecourse of a vessel such as the saphenous vein. The degree of rigidity orstiffness of the rigid tube 10 and internal components is determinedwith reference to its optical characteristics while under bendingforces. Specifically, adequate visualization must be provided via imagequality and light intensity during and after exertion of bending forceson the dissecting endoscope 9. Thus, no significant change in the image(i.e., loss of image at an edge of the field of view) should occurduring bending or deflection of the endoscope 9 by up to 10% of thelength thereof (i.e., about 40 mm deflection over about 405 mm ofworking length). Similarly, the optical characteristics evaluated afterdeflection of about 22% of the working length should indicate nopermanent optical damage or loss of image at an edge of the field ofview. The rigid tube 10 has a diameter of about 7 mm and includes one ormore segments 12, 14 of reduced diameter near the distal end tofacilitate attachment and sealing thereto of various surgical effectordevices and tip attachments. In one embodiment of the present invention,as illustrated in FIG. 1B, the rigid tube 10 of the dissection endoscope9 includes screw threads 17 disposed near the distal end along a distalsegment 12 of reduced diameter to mate with threads carried on asurgical effector device such as the tissue-dissecting tip 11.Additionally, the distal end of the rigid tube 10 may include anintermediate segment 14 of diameter greater than the distal segment 12and less than the rigid tube 10 to mate in axial alignment with acorresponding bore in a surgical effector device such as tip 11, therebyto facilitate alignment for threaded attachment of the tip 11 to thedistal segment 12 of the rigid tube 10.

The tissue-dissecting tip 11 includes rigid, transparent walls thattaper internally toward a cusp or apex and externally toward a blunt orrounded tip that facilitates dissecting tissue without puncturing thevessel being harvested or its side-branch vessels. The tip 11 is mountedforward of the distal end of the dissecting endoscope 9 within its fieldof view to provide visualization with low distortion of tissue beingdissected by advancement of the dissecting endoscope 9 and tip 11through tissue along the course of the vessel to be harvested (e.g., thesaphenous vein). Additionally, the tapered walls or center of the tip 11may carry markings to provide visual cues regarding the orientation andlocation of the tip 11 and endoscope 9 relative to a vessel beingharvested. In addition, translucent or colored (e.g., blue) tips 11 canbe used to aid in visualization and differentiation between tissue typesand structures.

A tissue-dilating collar 13 may optionally be disposed near the distalend of the dissecting endoscope 9, proximally displaced from the tip 11,to promote expansion of a cavity or anatomical space adjacent a vesselsuch as the saphenous vein as the dissecting endoscope 9 and attachedtip 11 are advanced through surrounding tissue along the course of thevessel to be harvested. The tip 11 and dilator 13 may be formed as anintegral assembly for threaded attachment, or other type of attachmentas later described herein, to the distal end of the dissecting endoscope9. The dilator 13 may be shaped similar to an olive to further expandtissue that is initially dissected by the tip 11 as the tip 11 anddilator 13 are advanced through tissue along the course of a vessel. Inaccordance with an alternative embodiment of the present invention, thetissue dilator 13 may include faceted surfaces 18 disposed about theperiphery thereof in the forward portion of the dilator, as shown inFIG. 2A. These faceted surfaces 18 reduce the frontal area of the tip 11and distal end of the dilator 13 that must penetrate tissue to create amore gradual transition to the maximum sectional dimension of thedilator, and thereby reduce the axial force required to be applied tothe dissecting endoscope 9 for dissecting and dilating tissue along thecourse of a vessel. Additionally, the faceted surfaces 18 form ridges 7that may be rotated within penetrated tissue to further reduce thelongitudinal forces required to dissect and dilate tissue along thecourse of a vessel. The proximal end of the dissecting endoscope 9includes fittings 15, 16 for attachment of a conventional medical cameracoupler (not shown), and a conventional fiber optic light guide (notshown), and the like. Of course, the tissue dilator 13 may also includea generally axially-aligned ribbed and fluted outer surface, asillustrated in FIGS. 2B and 2C, with the distal edge of the dilator 13displaced proximally from the tip 11.

Referring to FIGS. 3A-F, there are shown side and perspective views ofadditional other surgical effector devices 19, 20, 22, 24, 26 and 28that may be conveniently attached to the distal end of the dissectingendoscope 9 in mating engagement with the threads 17 carried by thedistal segment 12 of the endoscope 9. Specifically, various sizes andconfigurations of tissue dilators 19, 20, 22, with or without a taperedtissue-dissecting tip 11, may be secured to the distal end of thedissecting endoscope 9 via threaded engagement. Additionally, ahook-like extension, as illustrated in FIG. 3D, may be attached viamating threads to the dissecting endoscope 9 to facilitate trackingalong a saphenous vein around its intersections with side-branchvessels, and the like, within the field of view from the end of thedissecting endoscope 9. Similarly, an extension carrying a ‘C’-shapedforward edge, as illustrated in FIG. 3E, may be attached via matingthreads to the distal end of the dissecting endoscope 9 in order to passalong the course of the vessel and thereby facilitate cleaning off ofremaining adherent tissue within the field of view from the distal endof the dissecting endoscope 9. Also, a suture-positioning orknot-pushing extension, as illustrated in FIG. 3F, may be attached viamating threads to the distal end of the dissecting endoscope 9 tofacilitate ligating the vessel or side-branch vessels within the fieldof view from the distal end of the dissecting endoscope 9. And,tissue-dissecting tips of various optical characteristics, for example,as illustrated in FIG. 4, may also be attached via mating threads 17 tothe distal end of the dissecting endoscope 9 in optical alignmenttherewith. Specifically, the tissue-dissecting tip 29 may be formed as asolid transparent component with forward tapered conical walls taperingtoward a blunt tissue-dissecting tip 31 from an intermediate region ofgreater diameter that is aligned along tapering walls 30 which divergeat substantially the angle of the field of view from the distal end ofthe dissecting endoscope 9. Mating optical faces may include a concaverecess 32 intermediate the tip 29 and viewing end of the dissectingendoscope 9 to produce a specific magnification (e.g., telescoping orwide-angle) or non-magnification within the field of view of theendoscope 9.

It should be noted that other attachment structures may be formed nearthe distal end of the dissecting endoscope 9 to engage with varioussurgical effector devices. Specifically, as illustrated in FIG. 5, oneor more lateral protrusions 40 may be disposed near the distal end ofthe dissection endoscope 9 for longitudinal sliding fit along one ormore corresponding slots 21 in the internal bore 23 through the dilator13, to resilient abutment of an O-ring seal 25 against a proximalshoulder 27 within the bore 23. Further insertion of the dissectionendoscope 9 and protrusion 40 into the bore 23 facilitates rotationalorientation of the protrusion 40 along the distal shoulder 20, intoresilient engagement within detent 6 in the distal shoulder 20. The tip11 and dilator 13 are thus quickly detachable from the distal end ofendoscope 9 and are sealed onto the endoscope 9 by O-ring 25 compressedwithin bore 23 and abutting proximal shoulder 27. Alternatively, varioussurgical effector devices may be attached to the distal end of thedissecting endoscope 9 via various press-lock or snap-fit attachmentstructures as illustrated in FIGS. 6A and 6B. Specifically, oneembodiment of an attachment structure includes a resilient ring 35 nearthe distal end 36 of the dissecting endoscope 9 for mating with a ringedrecess 37 within the sliding bore 38 in the surgical effector device 40(e.g. a dissecting tip and dilator combination). In this embodiment, asolid, elastic dilator 39 may include an inwardly extending lip 41 neara proximal end of the dilator to form an elastic, fluid-tight sealagainst the outer perimeter of the segment of the dissecting endoscope 9with which the lip engages. A similar attachment structure may be formedwithin the tissue-dissecting tip directly in the absence of a tissuedilator attached to the proximal end of such tip.

In another embodiment, the attachment structure includes alever-actuated locking device, as illustrated in FIG. 6C. Specifically,the tissue-dissecting tip 42 (or a tissue dilator formed about theproximal end of such tip) carries one or more levers 46 that are axiallyaligned and are rotatable about a lateral pivot axis 47 to actuate alocking pin 49 mounted on the lever 46 on the proximal side of the pivotaxis 47. In this attachment structure, pressing the lever 46 on thedistal side of the pivot axis 47 elevates the locking pin 49 from itsmating recess in the dissection endoscope 9. Alternatively, the lockingpin 49 may be affixed to the dissection endoscope 9, and a mating recessmay be carried on the lever for similar press-to-unlock attachment of asurgical effector device such as a tissue-dissecting tip to the distalend of the dissection endoscope 9.

The dissection endoscope 9 thus initially configured with atissue-dissecting tip attached to the distal end may be used to dissecttissue away from a vessel such as the saphenous vein as the surgeongrasps the rigid body of the dissecting endoscope 9 near the proximalend thereof in order to manipulate the tip 11 through the tissue alongthe course of the vessel. To facilitate grasping and manipulating thedissecting endoscope 9, various styles of handles, as illustrated inFIGS. 7A and 7B, may be attached near the proximal end of the dissectingendoscope 9. In-line styles of handle such as illustrated in FIG. 7A andoffset styles of handle such as illustrated in FIG. 7B promote thesurgeon's comfort and control during use of the dissecting endoscope 9in the procedure as previously described to isolate a vessel such as thesaphenous vein for harvest from a patient's body.

Vessel Harvester.

Referring now to FIG. 8, there is shown an exploded view of a dissectionendoscope 9 and an overlying sheath or tool cannula 51 that supportsvarious surgical effector devices, as later described herein, and thatreceives the endoscope 9 axially within a lumen which extends betweenproximal and distal ends of the cannula 51. The tool cannula 51 may bemodified for orientation along side the endoscope 9 in a manner similarto configurations as later described herein, for example, with referenceto FIGS. 10-12. The tool cannula 51 has sufficient length to extend froma patient's knee to groin, or knee to ankle, or wrist to elbow. Thedissection endoscope 9 (or other endoscope) thus configured may be usedin the surgical procedures that are involved following dissection oftissue away from a vessel in order to harvest the vessel from thepatient's body. Specifically, the tool cannula 51 houses a pair ofelongated mating half shells 53, 55 that form separate lumens for anelongated scissor assembly 57 and a vein retractor 59, 60 and irrigationconduit 61. These devices are manually controllable at the distal end ofthe tool cannula 51 in response to control members 63, 65, 67 that aresupported within the mating housing shells 69, 71, and that are linkedto the surgical effector devices through the lumens of tool cannula 51.The tool cannula 51 and attached housing 69, 71 rotate about abell-shaped segment of the housing 73 that is retained in alignment withthe dissection endoscope 9 by snap-fit attachment to the light port 16thereon. This structure thus supports requisite surgical effectordevices, as later described herein in detail, for performing surgicalprocedures within an anatomical space that was previously dissected intissue adjacent the saphenous vein of a patient, in the manner aspreviously described. Specifically, the elongated scissors 57 include apair of rods 75, 77 disposed within a sheath 79. A pair of scissorblades 81 are pivotally mounted on an axle that is supported on thesheath 79, and the blades 81 are actuated through conventional linkageby the relative sliding movement of the rods 75, 77 within sheath 79.Rods 75, 77 may also serve as electrical conductors for applying bipolarcauterizing signals to the individual scissor blades 81, or toelectrodes supported thereon. Electrical connections are made to therods 75, 77 within the housing 69, 71 via cable 83 and the connector 85that extends from the housing. The scissor blades 81 may be selectivelyextended and retracted relative to the distal end of the tool cannula 51by sliding the control member 67 axially along the housing 69, 71 inengagement with the sheath 79. The control member 67 pivotally supportsthe lever 65 thereon that links to the rods 75, 77 in such manner thatrocking the lever 65 pivoted on the control member 67 advances andretracts the rods 75, 77 relative to the sheath 79 to operate thescissor blades 81 through shearing movement about their common pivot.

A vessel retractor 59 is also supported in the tool cannula 51 onsliding wire support 60, as shown in FIG. 8, for selective deploymentand retraction relative to the distal end of the tool cannula 51 inresponse to axial sliding movement along the housing 69, 71 of thecontrol member 63 that is linked thereto. The generally ‘C’-shapedvessel retractor 59 is supported near one side edge by the wire 60 andis supported near the other side edge by the tube 61 that slides withintube 62. In this way, a sliding fluid connection is provided to a nozzlein the vessel retractor 59 for washing the distal lens of the dissectingendoscope 9. The proximal end of the tube 62 is attached within thehousing 69, 71 to the flexible supply tubing 64 that extends from thehousing 69, 71 to a fluid connector 66. A resilient seal 88 is disposedwithin the tool cannula 51 about the support wire 60 and scissor sheath79 and supply tube 62 and an installed dissecting endoscope 9 tomaintain a gas-tight sliding seal during operation of the structurewithin an insufflated surgical environment. The control member 67 thatis slidably mounted on the housing 69, 71 may retain the scissor sheath79 in fixed angular orientation relative to the tool cannula 51 vialinkage to flat surfaces 76 near the proximal end of the scissor sheath79. Alternatively, the scissor sheath 79 may rotate axially relative tothe cannula 51 via linkage to an annulus or peripheral groove attachedto the sheath 79 near the proximal end thereof. Also, the distal endsegment 12 of the endoscope 9 may be reduced in diameter and support anattachment structure thereon, as previously described, and such segmentof reduced diameter, with no attachments thereon, also facilitatesnesting surgical effector devices within the distal end of the toolcannula 51. Such distal end 90 may include a chamfered or roundedforward edge to minimize snagging on tissue and to promotemaneuverability of the tool cannula 51 within a cavity of dissectedtissue along the course of a saphenous vein or radial artery.

Referring now to the perspective view of FIG. 9, the viewing end of theendoscope 9 (without tip 11) is disposed within the open distal end ofthe tool cannula 51, surrounded by, for example, supports 60, 61 for avein retractor 59, and the shaft 79 attached to bipolar scissors 81, asa representative set of surgical effector devices that are deployableand manipulatable relative to the distal end of the tool cannula 51.Other types of effector devices carried by the tool cannula 51 fordeployment and manipulation relative to the distal end thereof mayinclude, for example, one or more of an endoscope washing nozzle, a knotpusher for positioning a suture about the vessel being harvested, a clipapplier for occluding lateral or side-branch vessels, an irrigating orsuction port, a ligator, hot-element cauterizer, and a fork device, aslater described herein, for surrounding, cauterizing, ligating ortransecting side-branch vessels.

The vessel retractor 59, as a surgical effector device as shown in theillustrated embodiment of FIG. 9, is configured generally as a C-shapeddevice to slide along a saphenous vein or a vein adjacent a radialartery being harvested, and is mounted on resilient support 60, 61 forindependent deployment from the open distal end of tool cannula 51 inresponse to axial movement of the control member 63 slidably mounted inthe housing 69, 71 at the proximal end of the cannula 51. The resilientsupports 60, 61 of the vessel retractor 59 facilitate selective lateraldisplacement of a saphenous vein or radial artery pedicle in response tomanual manipulation of the control member 63 in a manner similar to thevein retractor that is more fully described, for example, in U.S. Pat.No. 6,162,173.

The bipolar scissors 81, as another surgical effector device, shown inFIG. 9 are supported on the distal end of sheath 79 for independentdeployment from the open distal end of tool cannula 51 in response tomanual sliding movement of a control member 67 shown in FIG. 8 that isslidably mounted in the housing 69, 71 at the proximal end of the toolcannula 51. In addition, the lever 65 shown in FIG. 8 that is pivotallysupported on the control member 67 may be manually manipulated about itspivot to selectively open and close the scissor blades 81 via thelinkage 75-77, as previously described. Alternatively, both the scissors81 and the retractor 59 may be slidably deployed together from the opendistal end of the tool cannula 51 in a configuration which includeslinking of the scissor blades 81 to the retractor 59 or to the supports60, 61 therefor. In such configuration, a selected distance or spatialseparation is maintained between a saphenous vein or radial arterypedicle being harvested and the location relative to a junction of aside branch with the saphenous vein or radial artery at which the sidebranch may be cauterized and transected by the bipolar scissors 81.

It should be noted that the surgical effector devices including vesselretractor 59 and bipolar scissors 81, or other surgical effector devicesfor electrocauterization and transection of tissue and vesselstructures, are mounted within the tool cannula 51 which may be fullyrotatable about the endoscope 9. This provides complete orbitalorientation about the elongated axis of the endoscope 9 that remains atsubstantially fixed rotational orientation for maximum versatility inretracting, ligating or cauterizing and severing tissue and vesselstructures within the viewing field forward of the endoscope 9. Viewedimages thus remain stably oriented for the user as the tool cannula 51and the surgical effector devices mounted therein are axially rotatedabout the endoscope 9 during vessel harvesting procedures. A pointerdevice or optical marker may be disposed within the viewing field of theendoscope 9 to provide visual orientation of the tool cannula 51relative to the axis of the endoscope 9 and to facilitate identificationof which surgical effector device is deployable and from what locationrelative to the images viewed through the endoscope 9.

Referring now to the partial perspective views of FIGS. 10, 11 and 12,there are shown perspective views of alternative embodiments of thevessel harvester according to the present invention. Specifically, adissecting endoscope 9 includes a tapered tissue-dissecting tip 91 thatis axially truncated to form a mating surface 93 for selectiveattachment thereto of a tool housing 95 and associated cannula 97 ineccentric orientation relative to the elongated axis of the dissectingendoscope 9. In this embodiment, the dissecting endoscope 9 includes anattachment structure of its distal end that includes a locking ferrule99 for quick mating engagement and disengagement with thetissue-dissecting tip 91. In one embodiment, such attachment structureincludes a lateral locking arm 101 which mates with a recess 103, asshown in FIG. 10, to inhibit axial and rotational movement of the tip 91thus attached at the end of the dissecting endoscope 9. Of course, otherattachment structures, for example, as previously described or asincluding insert 100 may be used to selectively attach thetissue-dissecting tip 91 to the distal end of the dissecting endoscope9.

The mating surface 93 on the tip 91 mates with a similar surface on toolhousing 95 which includes descending side walls 105, 107 that aredisposed to grip the sides of the tip 91 for firm seating and retentionof the attachment to the tip 91. In this configuration, surgicaleffector devices, for example, of the types described herein, may bemounted in the tool housing and attached cannula 97 for selectivedeployment and manipulation relative to the distal end of the assemblyusing control members (not shown) mounted near the proximal end of thecannula 97 via linkage and operation similar to those previouslydescribed herein. Such vessel harvesting structure may thus beselectively configured initially for use of the dissecting endoscopealone in dissecting tissue to create an anatomical space along thecourse of a vessel, with only the tip 91 attached to the dissectingendoscope 9. Thereafter, the tool housing 95 and cannula 97 withassociated surgical effector devices mounted therein may beeccentrically attached to the dissecting endoscope 9 to facilitatefurther surgical procedures within the anatomical space previouslydissected in tissue and incident to harvesting the vessel from apatient's body.

Surgical Effector Devices.

Referring now to the partial perspective views of FIGS. 13 and 14, thereare shown views of a rotary cauterizing and shearing device according toone embodiment of the invention that is deployable from the distal endof the tool cannula 51. Specifically, one cylindrical segment 45 havingan axially-aligned edge 48 may be extended from the distal end of thetool cannula 51, or alternatively may constitute a portion of suchdistal end. Additionally, another cylindrical segment 50 having an edge52 that is axially aligned or is skewed slightly is rotatable within thetool cannula 51 and within the segment 45 to provide rotational shearingaction along the mating edges 48, 52, as shown in FIG. 14. The edges 48,52 may also include adjacent electrodes (not shown) for supplyingelectrical or thermal energy to tissue such as side-branch vessels forcauterizing and occluding the vessels prior to shearing the tissue byrotationally overlaying the segments 45, 50 as shown in FIG. 14. Ofcourse, the deployment and manipulation of the segments 45, 50 toconfine and cauterize and ligate tissue within the edges 48, 52 may becontrolled from the proximal end of the tool cannula 51 via usingconventional linkage coupled therebetween.

Alternatively, as illustrated in the partial perspective views of FIGS.15A and 15B, tissue-shearing and electrocauterizing of tissue is greatlyfacilitated by configuring the distal end of the cannula 51 with agenerally ‘Y’-shaped or ‘T’-shaped slot 109, as shown. In thisconfiguration, an intact side-branch vessel may be manipulated into andthen captivated within the slot for convenient shearing in response tolateral extension or rotation of the mating inner segment 111 over theslot 109. Additionally, such shearing mechanism may be energized withelectro-cauterizing signal of one polarity, for example, on the cannula51 and slot 109 and of opposite polarity on the inner mating segment111.

In another embodiment of a tissue shearing structure according to thepresent invention, a hook-like extension 113 may be formed on the distalend of tool cannula 51, as shown in FIG. 16. In this configuration(analogous to a single lateral segment of the slot 111 in theillustrated embodiment of FIG. 15A) a side-branch vessel may becaptivated by the hook, and sheared or transected adjacent the hook inresponse to axial or rotational movement of blade 115 in close proximityto the hook 113.

Alternatively, cauterization and transection of side-branch vessels maybe performed using a structure as illustrated in FIG. 17. In thisembodiment, a blade 117 that is slidably mounted in the tool cannula 51is drawn in against an anvil formed by the distal end 90 of the toolcannula 51 to shear tissue or transect a vessel 119 between the bladeand anvil. Additionally, electrodes 121, 123 may be disposed on oppositesides of the blade 117 to establish bipolar electrocauterization of avessel 119 that is positioned against the blade 117 for cutting, andthat is therefore also positioned in contact with the electrodes 121,123.

Referring now to FIG. 18, there is shown another embodiment of atissue-cutting device formed at the distal end of the tool cannula 51.In this embodiment, a diametric slot 125 is formed in the distal end ofthe tool cannula 51 for receiving a side-branch vessel therein that isto be transected (and optionally cauterized). A cutter blade 126retracts within the tool cannula 51 past the depth of the slot 125 toaccommodate positioning of a side-branch vessel completely within theslot 125. Various keyhole or lateral extensions of the innermost segmentof the slot 125 may be provided to aid in retaining the side-branchvessel in position for electrocauterization and/or transection. Bareelectrodes 127, 129 may be disposed on opposite sides of the slot 125(on one diametric side of the cannula 51) to provide requisite spacingfrom the intersection of the vessel with a side-branch vessel to thelocation thereon at which cauterization and transection are to beperformed. The electrodes 127, 129 may be disposed at differentdiameters of the tool cannula 51 to overlap over the slot 125 withouttouching in order to assure electrical contacts with the side-branchvessel for effective electrocauterization, and to assist in captivatingthe vessel within the slot 125 during transection. In these embodiments,the cutter blade 126 may be mounted within the tool cannula 51 to rotateor translate across the slot 125 for transecting a side-branch vesseldisposed within the slot 125.

Alternatively, as illustrated in FIG. 19, a tissue-shearing structuremay be incorporated with another surgical effector device such as atissue-dissecting tip. In this illustrated embodiment, a slot 130 isformed in one wall of the tissue-dissecting tip 131 to permit ahook-shaped cutter blade 133 to extend axially through the slot 130 inpreparation for captivating within the hook-shaped blade 133 aside-branch vessel to be transected. Additionally, bipolar electrodes135, 137 may be disposed close to the slot 130 on opposite sides thereoffor contacting a vessel to be transected while captivated by thehook-shaped blade 133.

Referring now to FIGS. 20A and 20B, there are shown pictorialillustrations of mating half sections of forceps jaws 141, 143 that areslidably mounted within tool cannula 51 and that, closed, form atissue-dissecting tip 145 which is suitably shaped for performing blunttissue dissection. The forceps jaws 141, 143 may be configured asbipolar electrodes, as shown in FIG. 20B, for clasping andelectro-cauterizing a side-branch vessel. A cutting blade 147 may bemounted for selective positioning within the jaws 141, 143 (e.g., as byaxial movement from within tool cannula 51) in order to facilitatetransecting a cauterized vessel upon closure of the jaws 141, 143 aboutthe vessel.

Referring now to FIGS. 21A and 21B, there are shown pictorialillustrations of another embodiment of a tissue cauterizing and shearingstructure according to the present invention. Specifically, a relativelyinflexible coil 151 is disposed about a central conductor 153 that isspaced away from the inner surfaces of the coil 151 to receiveelectrocauterizing bipolar signals selectively supplied to the coil 151and conductor 153. As shown in FIG. 21B, a side-branch vessel 155 iscaptivated between adjacent convolutes of the coil 151 to contact boththe coil 151 and conductor 153 during electrocauterization of theside-branch vessel 155. For this reason, the pitch of the coil 151 isselected to leave spacings between adjacent convolutes of approximatelythe dimensions of side-branch vessels 155 likely to be encounteredduring harvesting of a saphenous vein. Alternatively, the pitch of thecoil 151 may vary over the exposed length thereof to provide a range ofspacings between adjacent convolutes that can accommodate the variationsin the dimensions of side branch vessels 155 that are encountered duringsuch harvesting procedures. The coil 151 and center conductor 153 aresubstantially coaxially positioned by insulator 157 at the distal end ofthe coil and at a proximal end (not shown) within the supporting sheath159. Tissue-shearing action is achieved by relatively axially slidingthe overlying sheath 159 along the length of the coil 151 to sever aside-branch vessel that is captivated between adjacent convolutes of thecoil 151 via a sharpened leading edge of the sheath 159. Alternatively,the coil 151 may overlay the sheath 159 that is disposed within the coil151 in close proximity of the inner dimensions of the coil 151 andoverlaying the central conductor 153. In this configuration, side-branchvessels that are captivated between adjacent convolutes of the coil 151are severed via a sharpened leading edge of the inner sheath 159 as itis moved axially through the coil 151.

In another embodiment of this electrocauterizing and tissue-shearingstructure, a resilient coil 151 and central conductor 153 are mountedfor relative movement in order to facilitate collapsing the coil 151axially and thereby diminishing the pitch substantially to zero. Thus,side-branch vessels that are captivated within the space betweenadjacent convolutes of the coil 151 while maximally extended are thensevered as the convolutes of the coil are compressed. Substantiallyflat-wound convolutes of coil 151 with sharpened adjacent lateral edgesgreatly facilitate severing a side-branch vessel captivated betweenadjacent convolutes. Such electrocauterizing and tissue-shearingstructures may be substituted for bipolar scissors of the typespreviously described herein for use similarly in combination with avessel retractor, or as otherwise manipulated from the distal end of thevessel harvester.

Referring now to the partial perspective view of FIG. 22, there is shownanother surgical effector device that may be selectively deployed andmanipulated from the distal end of cannula 51 under manual control fromthe proximal end of the cannula 51. Specifically, scissor blades 81 mayinclude an aperture 43 through, or a closed channel along (not shown),one or more of the blades 81 for selectively positioning a suture loop 8about a vessel to be occluded and severed for harvesting from the body.

Referring now to FIGS. 23A, 23B and 23C, there are shown partial top andside views of another surgical effector device for electrocauterizingand shearing tissue during a vein-harvesting procedure. In thisembodiment, a pair of scissor blades 161, 163 are pivotally mounted on asupporting body 165 for rotation about a pivot 167. In addition, thebody 165 also supports a bale 169 spaced about the periphery of theblades 161, 163 and lying substantially in the plane of the pivot 167.In this embodiment, the blades 161, 163 are operable in conventionalmanner from a proximal location via linkage that couples the blades 161,163 to a manual control member at the proximal location, in a manner aspreviously described herein. In addition, the blades 161, 163 may servein common as an electrode for one polarity of electrocauterizing signal,and the peripheral bale 169 may serve as an electrode for the oppositepolarity of electrocauterizing signal. In this configuration, the blades161, 163 together in closed configuration and the peripheral bale 169may function as spaced bipolar electrodes for contacting andelectrocauterizing tissue. Alternatively, the blades 161, 163 in openconfiguration and the peripheral bale 169 may captivate a side-branchvessel therebetween for electrocauterization and transecting thereof inefficient manner, particularly if the supporting body 165 is mounted toconstrain angular orientation of the blades 161, 163 relative toorientation of a side-branch vessel to be cauterized and transected.

Referring now to FIGS. 24A and 24B, there are shown partial top and sideviews of another cauterizing and transecting structure in accordancewith the present invention. In this structure a pair of resilient wireelectrodes 171, 173 are disposed to lay in substantially a common planeover portions of their respective lengths and areas and are spaced awayfrom each other to serve as bipolar electrodes. Alternatively, theelectrodes can lie in parallel or skewed planes, or can twist andtransition between reference and orthogonal orientations, as illustratedin FIGS. 24C-24I. Accordingly, side-branch vessels captivated betweenthe electrodes 171, 173 resulting from resilient deflection of theelectrodes out of the common plane may be electrocauterized byapplication of signals thereto of opposite polarities. Additionally, ablade 175 with a forward cutting edge or tapered side edge or hookedrearward-facing edge is mounted within body 177 for axial slidingmovement within the boundaries of the electrodes to transect aside-branch vessel captivated between the resilient electrodes 171, 173.This structure is typically mounted for convenient axial rotationrelative to the course of a side-branch vessel in order to align thestructure with a side-branch vessel disposed within the substantiallycommon plane of the electrodes.

Referring now to FIGS. 25A, 25B, 25C and 25D, there are shown partialperspective views of alternative structures for cauterizing tissue. Inthese embodiments, wire structures 181, 183 are disposed inspaced-apart, substantially plane-parallel orientation at the distal endof supporting body 185. Additionally, these electrodes 181, 183 may bedisposed within or on, or form a portion of, a clear plastic conicalsection or wire cage 187 configured as a tapered tip for bluntlydissecting tissue. In each configuration, the spaced electrodes 181, 183are connected to receive electrocauterizing signals of oppositepolarities, and may be sufficiently resilient to compress through andthereby sever cauterized tissue in side-branch vessels captivatedbetween the electrodes 181, 183.

Referring now to the partial perspective views of FIGS. 26A and 26B,there is shown a surgical effector device including a fork-like device143 having spaced, forward-projecting tines that are disposed tosurround side-branch vessel 145 of a vessel 146 being harvested. Eachtine includes an electrode 150 that intrudes from the forward end towardthe other electrode 152 to form a slot 154 therebetween to admit aside-branch vessel 145 therethrough into the recess between tines. Thus,a side-branch vessel 145 positioned in the slot 154 between electrodes150, 152 may be electrically or thermally cauterized and occluded byelectrical or thermal energy supplied to the electrodes, as shown inFIG. 26B, prior to being transected by cutter blades 151 positionedwithin the recess of the fork 143 behind the slot 154 between electrodes150, 152. Of course, other configurations of cutter blade or blades 151than rotary or circular blades as shown may be arranged behind the slot154 between electrodes to sever a vessel as the fork-like device 143 isadvanced along the course of the vessel being harvested 146 through andpast a side-branch vessel 145. For example, angled fixed cutting edge oredges and movable hook-like or lateral cutting blades may also bedisposed within the fork-like device 143 behind the electrodes 150, 152for ligating cauterized side-branch vessels.

In another embodiment, as illustrated in the partial perspective viewsof FIGS. 27A and 27B, a fork-like device 191 serves as a retractor forcaptivating a side-branch vessel 193 as the vessel 195 is deflected ordepressed. Specifically, the forward ends of the fork-like device 191include flexible gates 197, 198 that are mounted to traverse the centralslot 199 between the front ends of the fork-like device 191. These gates197, 198 exhibit variable resilient bias toward closure over the frontend of the slot 199 that is easily overcome to admit the side-branchvessel 193 through the gates 197, 198 for captivation within the slot199 upon forward movement of the device. However, the gates 197, 198exhibit stiffer resilient bias perpendicular to the vessel 195 in orderto retract the vessel 195 as the side-branch vessel 193 within the slot199 is cauterized and transected.

In one embodiment, as illustrated in FIG. 28, the gates 201, 203 at thefront end of the fork-like device 205 may be disposed on a top surfaceof the device near the forward end for pivotal movement in opening andclosing to receive and captivate a side-branch vessel within the slot207 of the device 205. Alternatively, as shown in FIG. 29, the fork-likedevice may be configured as a descending U-shaped retractor 209supported on one or more resilient support wires 211. To facilitateplacing the retractor 209 about the vessel 213 in proximity with aside-branch vessel 215, the support wires 211 may be configured in closeproximity to a narrowed region 210 behind the retractor 209, as shown inFIGS. 30A and 30B, to diverge from parallel support wires orparallel-edged structure to facilitate convenient manipulation aboutintersections of side-branch vessels with the harvested vessel. Inalternative embodiments of the invention, as illustrated in FIG. 31, thegates may be formed as thin wire loop 221, 223 attached to resilientwire supports 225, 227.

Referring now to FIG. 32, there is shown a perspective view of theinverted U-shaped vessel retractor 59 of FIG. 8 configured forattachment to one or more resilient supports. At least one such wiresupport 60, as shown in FIG. 8, attaches within bore 237, and asupporting hollow tube 61, as shown in FIG. 8, attaches within bore 235that is channeled to an outlet orifice 238. This orifice serves as anozzle for spraying liquid onto an adjacent lens of an endoscope, or forotherwise supplying liquid to a surgical site. An aperture 239 isprovided in one leg of the retractor 231 for selectively positioning asuture loop about a vessel to be occluded and severed for harvestingfrom the body. Alternatively, a suture loop 8 may be manipulatedrelative to a vessel in a manner similar to the manner as previouslydescribed with references to FIG. 22. In this configuration, the vesselretractor may be deployed from the distal end of a supporting body undermanual manipulation from a proximal end of such body.

Referring now to FIG. 33, there is shown another embodiment of a vesselretractor including a pair of resilient support wires 241, 243 that aredisposed to slide within the supporting body 245, and that support aflexible sling 247 therebetween near the distal ends thereof. In thisconfiguration, a vessel may be contacted and retracted by the flexiblesling 247 that is tensioned taut by the divergent orientation of theresilient support wires 241, 243. Upon slidable retraction of thesupport wires 241, 243 into the distal end of the supporting body 245,the flexible sling 247 is confined between the support wires 241, 243that converge toward parallel orientation as retracted into the supportbody 245.

Control Members for Vessel Harvester.

Referring again to FIG. 8, and to FIGS. 34A-34I, there are shown theexploded and perspective views of the vessel harvester and associatedcomponents according to one embodiment of the present invention. Theleft half section 71 of the handle is shown inverted for clearillustration of internal structure. In this embodiment, the surgicaleffector devices described herein are manipulatable at the distal end oftool cannula 51 in response to manual manipulation of control members63, 65 and 67 mounted in the handle of the device that is attached tothe proximal end of the tool cannula 51. Specifically, the handleincludes a rear bell-shaped section 73 that remains oriented in fixedaxial alignment with a light post 16 of an endoscope 9 that is receivedin snap-fitting engagement within the side slot 74. This bell-shapedsection 73 includes a rear aperture 78 that receives a conventional eyepiece or camera attachment to an endoscope disposed within the section73, and includes a front end 80 of the rear section 73.

This rear section 73 rotatably attaches to left and right half sections69, 71 of the forward section of the handle that are formed as shown inFIGS. 34A and 34B. Components, as later described herein, are assembledin the left half section 69, and the right half section 71 is thenattached to complete the handle. In this configuration, the left andright half sections rotate about the bell-shaped rear section 73 whichattaches at flange 260 disposed within annular groove 274. The halfsections 69, 71 slidably support the control member 67 shown in FIG. 34Dwhich, in turn, supports thereon a pivot carriage 70 shown in FIG. 34Ethat links to the outer sheath 79 of the bipolar scissors 81. The slot76 near the proximal end of the outer sheath 79 slides into and iscaptivated within the slot 72 in pivot carriage 70. Thus, sliding thecontrol member 67 back and forth axially along the longitudinal slot 68shown in FIG. 34B formed in the left and right half sections 69, 71retracts and deploys the scissor assembly 81 relative to the distal endof tool cannula 51.

The pivot carriage 70 illustrated in FIG. 34E supports a rocking lever65 shown in FIG. 34F on integral pivot shaft 86 that is orientedlaterally to the direction of slidable movement of the control member67. The rocking lever 65 includes a lever arm 89 that engages the rods75, 77 shown in FIG. 8 which extend from the proximal end of the sheath79 of the scissor assembly. Thus, rocking the lever 65 about its pivotshaft 86 linked in this manner to the scissor blades 81 causes theblades to open and close in scissor-like motion.

The left and right half sections 69, 71 of the handle also slidablysupport a control member 63 shown in FIG. 34G for movement back andforth in the longitudinal slot 92 shown in FIGS. 34B and 34C formed inthe left and right half sections 69, 71. The control member couples tothe activating rod 61 shown in FIG. 8 of the vein retractor 59 via theangled end 294 that engages within the groove 303 and aperture 305 shownin FIG. 34G. Thus, sliding the control member 63 back and forth withinthe slot 92 retracts and deploys the vessel retractor 59 from the distalend of the tool cannula 51.

The sheath 79 shown in FIG. 8 supporting the scissor assembly 81 slideswithin the lumen 314 shown in FIG. 34H that is formed in right and lefthalf inserts 53, 55 shown in FIGS. 34H and 34I. In addition, anendoscope is slidably supported within the lumen 316 that is formed bythe inserts 53, 55, and the rod and tube 60, 61 shown in FIG. 8 thatsupport the vessel retractor 59 and are slidably supported within theouter grooves 312, 313 formed within the left and right inserts 53, 55.

Referring now to FIG. 35, there is shown another embodiment of thecontrol members mounted at the proximal end of the tool cannula 51 formanipulating surgical effector devices at the distal end thereof.Specifically, in this embodiment one or more coaxial sheaths 301, 302are disposed about the endoscope 9 to facilitate axial or orbitalrotation of the surgical effector devices relative to the axis andorientation of the endoscope 9. The ring 304 on sheath 302 may be slidaxially to deploy and retract the vessel retractor at the distal end ofthe sheath 302, and the axial compression assembly 306 is linked to thescissors mounted at the distal end of the sheath 301 for deployment andretraction thereof by squeezing or releasing assembly 306. Forwardsliding movement of the axial compression assembly 306 deploys thescissors, and relative axial compression of the forward and rearwardcomponents of the compression assembly 306 actuate the scissor blades inany selected angular orientation about the endoscope 9 to facilitatetransecting side-branch vessels encountered lying in any orientationrelative to the vessel that is to be harvested.

Referring now to FIG. 36, there is shown another embodiment of controlmembers disposed at the proximal end of tool cannula 51 for manuallymanipulating at the distal end thereof the selected surgical effectordevices that are linked to the control members. Specifically, thecontrol member 308 slides forward toward the distal end of the toolcannula 51, for example, to deploy the vessel retractor from the distalend of the tool cannula 51. And, separately slidable rings 311, 313 aresupported on the tool cannula 51 and are linked, for example, toscissors at the distal end of the tool cannula 51 to deploy and retractthe scissors in response to sliding the rings 311, 313 together, and tooperate the scissors to transect tissue in response, for example, tosliding movement of the proximal ring 311 proximally relative to ring313 in order to close the scissor blades.

Referring now to FIG. 37 there is shown an exploded perspective sideview of the package of components suitable for use in harvesting avessel from a patient's body. Specifically, a pre-formed container 332includes a lower tray 334 having a peripheral ridge 335 about its uppersurface, and an upper lid 336 for closing the tray 334 having a recess338 in the peripheral flange that conforms to the ridge 336 for forminga seal at least against particulates from intruding into the confinedvolume between the tray 334 and lid 336. The tray 334 includes anelongated recess 340 along a portion of the bottom that is elevated to amid-height level for receiving the tool cannula 51 therein. The elevatedbottom includes one or more recesses 342, 344 for confining a number ofdissecting tips 11 of different configurations, for use as previouslydescribed herein, and a syringe 341 for attachment to the fluidconnector 66 shown in FIG. 8 for delivering fluid under pressure to washthe endoscope lens, as previously described herein. The remaining,unelevated portions of the bottom of the tray 334 provide internal spacefor the handle assembly 69, 71, 73, and to provide exterior supports352, 354, or pods, on which the tray 334 may stably rest. The upper lid336 includes a depression 356 that descends closely to the elevatedportion of the bottom at mid-height level that includes the recesses340, 342, 344 for retaining the components previously described hereinin the respective recesses. This entire structure 332 may be vacuumformed of thermoplastic sheet material such as PTFE or PETE polymers.The components of the container 332 and the surgical components housedin the container may be substantially assembled as shown forsterilization processing and sealing within an outer envelope 358 ofthin flexible impervious plastic material of the types, for example, aspreviously described above.

The sterilized components within the sealed envelope 358 are disposedwithin an external carton 360 that provides additional protection fromdamage during shipping and handling. In addition, the carton 360contains another sealed envelope 362 in the region beneath the elevatedbottom portion of the tray 334. This sealed envelope 362 contains asurgical access port of the type, for example, as illustrated anddescribed in U.S. Pat. No. 6,811,546, entitled “Endoscopic SurgicalAccess Port and Method”, filed on Aug. 25, 2000 by P. Callas et al. Suchsurgical access port includes a blunt-tip hollow trocar that facilitatesoperation of the dissecting endoscope 9 and tool cannula 51 withininsufflated surgical environments, and that may therefore be included inthe packaging discussed above for the convenience of a surgeon havingthe components available with which to perform a vessel-harvestingprocedure.

In general, with reference to the flow chart of FIGS. 38A and 38B, therigid dissecting endoscope 9 as illustrated in FIG. 1B may be insertedthrough a seal 347 that is affixed to an outer, hollow barrel of agas-sealing trocar of a type, for example, as disclosed inaforementioned U.S. Pat. No. 6,811,546. Thus, tissue dissection underinsufflation may be accomplished 364 along the vessel to be harvestedusing the elongated dissecting endoscope 9 inserted through the slidinggas seal, and fitted with a blunt tissue-dissecting transparent taperedtip 11. Connecting tissue may be dissected away from the vessel beingharvested, under visualization through the tip 11, in response to manualmanipulation of the proximal end of the endoscope 9 that advances thetip 11 and optional tissue dilator 13 through tissue surrounding thevessel along the course thereof.

Following such tissue dissection to form an anatomical space or cavityalong a segment of the vessel, the endoscope 9 may be withdrawn 365 fromsuch cavity through the sliding gas seal of the hollow trocar, and maythen be reconfigured by detaching 367 the tapered tip 11, and by sliding369 over the length of the endoscope 9 the overlying tool cannula 51that carries the surgical effector devices including the retractor 59and scissors 81, as previously described. The tapered, transparent tip11 may optionally be retained on the viewing, distal end of theendoscope 9 and overlayed by the tool cannula 51 that slides into placeover the length of the endoscope 9, or alternatively that attachescontiguously and eccentrically to the endoscope, as previously describedherein.

This configuration of tool cannula 51 overlaying or otherwise attachedto the endoscope 9, may again be slidably inserted 371 through theresilient gas-seal of the hollow trocar to position the surgicaleffector devices mounted at the distal, open end of tool cannula 51 forretraction, cauterization and transecting of vessel structuresencountered within the anatomical space previously formed by blunttissue dissection along the course of the vessel being harvested. In oneembodiment, for example, the dissection endoscope 9 may be suppliedseparately packaged for resterilization prior to each use. Thecooperating components such as tips 11 and dilators 13, and one or moretool cannulas 51, each with a selected set of effector devicesdeployable and manipulatable at the distal end of the tool cannula 51,and (optionally) a gas-sealing hollow trocar are therefore suppliedtogether for convenience in sterilized condition as packaged withinrespective hermetically-sealed envelopes 358, 362 and housed withincarton 360. Thus, for each vein harvesting procedure there need only besupplied in a kit a trocar and a tool cannula 51 with its selectedeffector devices carried thereby, and selected effector devices forattachment to the dissection cannula, and a syringe 341 for performing avessel harvesting operation with a reusable dissection endoscope 9.

Specifically, as illustrated in the flow chart of FIGS. 38A and 38B, thesurgical apparatus of the present invention facilitates the surgicalprocedures for harvesting a vessel such as the saphenous vein from apatient. The surgical procedure includes forming an initial smallincision 353 over the vessel such as the saphenous vein to permit asurgeon to bluntly dissect tissue 355 down to the adventitia layer andto expose the saphenous vein. When insufflation is indicated to inflateand expand the anatomical space to be formed along the vessel, then ablunt-tip trocar may be installed 347 on the dissecting endoscope 9which is then inserted 349 into the initial incision and advanced alongthe vessel a sufficient distance to install 351 the hollow trocar in theincision. The hollow barrel of the trocar includes an inflatable balloonabout the outer circumference of the distal end, and such balloon isinflated following insertion 357 of the trocar within the initialincision to anchor the trocar in gas-tight sealing orientation withinthe initial incision. Gas under pressure is then supplied through thetrocar to insufflate 363 the dissected cavity.

The dissection endoscope 9, with the blunt tapered transparent tip 11attached to the distal end thereof and with the shaft of the dissectingendoscope disposed within the sliding gas seal and through the innerbore of the trocar, is now advanced 364 along the vessel to complete theblunt tissue dissection along the vessel while visualizing the tissuedissection through the transparent tip 11 at the distal end of thedissection endoscope 9. The blunt dissection of connecting tissue awayfrom the saphenous vein and around tributary vessels may proceed onanterior and posterior sides of the vein along the course of the vein tothe full extent or length of the dissecting endoscope 9 by manualmanipulation of the proximal end thereof that protrudes from the slidinggas seal of the trocar. Tissue dissection can be assisted by palpatingtissue through skin in known manner in order to manipulate tissue towardand around the tip 11.

Upon completion of tissue dissection with the dissecting endoscope 9along the course of the vessel, in one or opposite directions from theinitial incision, the dissecting endoscope 9 is withdrawn 365 from thecavity through the sliding gas seal of the trocar, and the bluntdissecting tip 11 may be detached 367 from (or alternatively retainedon) the distal end of the endoscope 9 to accommodate reconfiguration ofthe endoscope for the next phase of the vessel-harvesting procedure.Specifically, with the tip 11 (and optional dilator 13) removed from thedistal end of the dissection endoscope 9, the overlying tool cannula 51may be slid onto the distal end and full length of the dissectionendoscope 9 (or other scope) to equip the endoscope 369 with, forexample, a set of surgical effector devices such as a vein retractor 59and bipolar scissors 81 needed to prepare the lateral or side-branchvessels for transection from the vessel to be harvested. In analternative configuration, the transparent tip 11 may remain attached tothe distal end of the endoscope as reconfigured with the overlying oradjacent eccentric cannula, as previously described herein.

The endoscope 9 and tool cannula 51 with associated retractor 59 andscissors 81 recessed within the open distal end of the tool cannula 51is inserted 371 through the sliding gas seal of the trocar into theinsufflated cavity. Under visualization through the endoscope 9, eachlateral or side-branch vessel that is encountered along the course ofthe saphenous vein is cauterized using bipolar electrodes disposed onthe blades of scissors 81, as selectively deployed from the open distalend of the tool cannula 51, and is transected by the scissors 81 inconventional manner using the control members 65 and 67 in the handle atthe proximal end of the tool cannula 51 to operate the scissor blades81. Of course, other surgical effector devices such as ligating andtransecting instruments, vessel retractor, endoscope washer,RF-energized or ultrasonic or thermally-hot cauterizer, and the like maybe supported by the tool cannula 51 for selective deployment from theopen distal end of the tool cannula 51, as previously described herein.The retractor 59 on shaft 60 may be deployed from the open end of thetool cannula 51 and positioned about the vessel to laterally displace orretract its position 373 relative to a side branch that is to becauterized and transected using the bipolar scissors 81.

After all side branches encountered along the segment of the vessel thatis isolated within the insufflated cavity have been ligated, cauterizedand transected, the vessel may be occluded and severed in conventionalmanner at the remote ends of the desired segment for removal 375 fromthe cavity, for example, through the initial incision.

As illustrated in the flow chart of FIGS. 39A and 39B, the surgicalapparatus of the present invention also facilitates the surgicalprocedures for harvesting a vessel such as the radial artery from apatient. Specifically, the surgical procedure includes marking the skinat the wrist 381 overlying the pulse of the radial artery, asillustrated in FIG. 1A. The lower arm is wrapped 383 with an elasticband such as an Esmarch bandage to force blood out of the lower arm. Aninflatable tourniquet is then applied 385 to the upper arm to preservethe bloodless condition of the lower arm. The Esmarch bandage is removed387 and an incision is made 389 in the wrist at the spot previouslymarked to indicate the location of the radial artery. Metzenbaumscissors are used to bluntly dissect tissue 391 within the incision toexpose the radial artery and the adjacent venae comitantes veins.

A hollow short trocar is disposed over the dissecting endoscope, and thetapered tip is inserted through the incision 393 onto the anterioraspect of one of the veins lying adjacent to the radial artery. Thedissecting tip is advanced sufficiently far along the vein to allow aballoon on the exterior surface of the trocar to be inflated intogas-sealing position within the incision 395. Gas under pressure issupplied through the trocar to insufflate the lower arm as thedissecting endoscope is advanced 397 through tissue along the course ofthe vein to the antecubital space about the elbow. The tip of thedissecting endoscope is pulled back to the trocar and is advanced alongthe posterior aspect of the vein. Then, tissue dissection is similarlyperformed on the adjacent vein 397, and the tip of the dissectingendoscope is then used to expose 401 veinous and arterial side branchesalong the length of the dissected cavity until a pedicle of the radialartery and the paired venae comitantes has been isolated. The dissectingendoscope is then removed from the dissected cavity, and is reconfiguredwith the overlying or adjacent tool cannula, as previously describedherein, for reintroduction 403 through the trocar into the dissected andinsufflated cavity. The isolated veinous and arterial side branches andtributaries are then cauterized and transected along the length of theisolated pedicle 405 in a manner as previously described herein,commencing with such side branches and tributaries nearest the wrist andprogressing toward the elbow. A counter incision is performed at theelbow and the pedicle of radial artery and paired veins is ligated witha suture and is transected 407. The pedicle is similarly ligated andtransected at the wrist 409 for removal of the pedicle from thedissected cavity. The tourniquet is then removed, and any bleedingvessels are cauterized and the incision closed to complete theharvesting 411 of the segment of the radial artery from the lower arm.

Therefore, the apparatus and method according to the present inventionimprove the surgical procedures for harvesting a vessel from a patientwith reduced trauma to the patient. The convenient operability of areconfigurable dissection endoscope and associated tool cannula as asupport at the distal end thereof for various surgical effector devicesgreatly facilitate the surgical procedures for preparing the vessel insitu for removal from the body.

1. Apparatus for selective positioning over a portion of the length ofan endoscope for selectively performing tissue manipulation in the bodyof a patient, the apparatus comprising: an elongated cannula havingdistal and proximal ends and having an inner bore therebetween ofdiameter sized to slidably and rotatably receive an endoscope therein; asurgical effector device disposed near the distal end of the cannula forrotation with the cannula about an endoscope received therein anddisposed for selective movement relative to the distal end of thecannula; and a control member supported by the cannula near the proximalend thereof and linked to the surgical effector device for selectiveactuation thereof to manipulate tissue near the distal end of thecannula within a field of view of an endoscope disposed therein inresponse to manual actuation of the control member.
 2. Apparatus as inclaim 1 including a handle structure attached to the cannula near theproximal end thereof and supporting the control member thereon formovement relative to the cannula and handle structure linked through thecannula to the surgical effector device.
 3. Apparatus as in claim 2 inwhich the handle structure is substantially aligned with the cannula ineccentric spaced orientation thereto.
 4. Apparatus as in claim 1including a vessel retractor as the surgical effector device supportedby the cannula for slidable deployment and retraction relative to thedistal end of the cannula in response to actuation of the control membersupported on the handle structure and linked through the cannula to thevessel retractor.
 5. Apparatus as in claim 4 in which the vesselretractor is mounted for movement relative to the distal end of thecannula for displacing a tissue structure laterally relative to theelongated cannula in response to actuation of the control member. 6.Apparatus as in claim 5 in which the vessel retractor includes avessel-confining structure disposed forward of the distal end of thecannula for retaining a vessel as a tissue structure during lateraldisplacement thereof in response to manual manipulation of the controlmember linked to the vessel retractor.
 7. Apparatus as in claim 5 inwhich the vessel-confining structure of the vessel retractor includes agenerally inverted C-shaped recess disposed between a pair ofaxially-extending supports.
 8. Apparatus as in claim 7 in which theinverted C-shaped recess is substantially aligned with the elongatedcannula and is configured to overlay a distal end of an endoscopedisposed within the cannula.
 9. Apparatus as in claim 7 in which thepair of axially-extending supports for the vessel retractor aresubstantially parallel aligned within the cannula and are resilientlybiased laterally away from alignment with the elongated cannula forlaterally displacing the vessel retractor in response to axial extensionthereof distally of the distal end of the cannula.
 10. Apparatus as inclaim 9 in which a proximal edge of the vessel retractor between thepair of supports includes a substantially V-shaped recess.
 11. Apparatusas in claim 9 in which each of the pair of supports includes an inwardrecess located at adjacent positions along the supports near the vesselretractor.
 12. Apparatus as in claim 9 in which one of the pair ofsupports is configured as a tube for passing a fluid therethrough to thedistal end of the cannula.
 13. Apparatus as in claim 8 in which one ofthe pair of supports is configured as a tube having a distal openingoriented toward a distal end of an endoscope disposed within thecannula.
 14. Apparatus according to claim 1 comprising: a plurality ofsurgical effector devices supported by the cannula near the distal endthereof, each for different manipulations of tissue; a plurality ofcontrol members supported by the cannula near the proximal end thereof,each linked to a respective one of the plurality of surgical effectordevices for selective actuation thereof to manipulate tissue differentlynear the distal end of the cannula in response to manual actuation ofthe respective control member.
 15. Apparatus as in claim 14 in which oneof the surgical effector devices includes a cutting device capable ofcutting tissue near the distal end of the cannula in response to manualactuation of the control member near the proximal end of the cannula;and another of the surgical effector devices includes a vessel retractorconfigured to engage a vessel for the displacement thereof laterallyrelative to the distal end of the cannula in operable position slidablyextended forward of the distal end of the cannula.
 16. Apparatus as inclaim 15 in which the retractor is deployed with the cutting device todisplace a vessel laterally relative to the distal end of the cannula inthe operable positions of the retractor and cutting device forward ofthe distal end of the cannula.
 17. A method of dissecting a vesselwithin the body of a patient using an endoscope with an overlyingcannula supporting a surgical effector device, the method comprising:forming an incision to expose the vessel; advancing the cannula throughthe incision and along the course of the vessel to bluntly dissecttissue therefrom for forming an anatomical space about the vessel andexposing side-branch vessels thereof under visualization through anendoscope disposed within the cannula; manipulating with the surgicaleffector device supported by the cannula any side-branch vessels exposedwithin the anatomical space along the course of the vessel undervisualization through the endoscope; and severing the vessel for use asa bypass conduit.
 18. The method according to claim 17 includingdeploying from the distal end of the overlying cannula a vesselretractor as the surgical effector device for selectively laterallydisplacing the vessel during severing of side branches therefrom undervisualization through the endoscope.
 19. The method according to claim17 including selectively rotating the overlying cannula about theendoscope to position the surgical effortor device for severingside-branch vessels under visualization within the field of view of theendoscope.
 20. A kit of surgical apparatus for performing surgicalprocedures, the kit comprising: an elongated cannula having a boretherethrough between distal and proximal ends thereof for slidably androtatably receiving an endoscope therein, the cannula supporting anumber of surgical utilization devices including a vessel retractor nearthe distal end of the cannula for selective manipulation in response toa corresponding number of control means supported near the proximal endof the cannula and linked to corresponding surgical utilization devices;and, a container enclosing the cannula to form an hermetic sealthereabout and maintain a sterile environment therein about the cannula.